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... <br /> s <br /> STATE OFCALIFORWA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> �Y . <br /> anNd <br /> COMPLETE THIS FORM FOR EACH F (SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS — NEAREST CROSS STREET PARCEL$(OPTIONAL) <br /> C / re sn <br /> CITU NAME 5>L �— STATEA ZIP CODE SITE PHONE#WITH AREA CODE <br /> TOINDIC TE O CORPORATION Q INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY �COUNTY-AGENCY O STAT6AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS ED 1 GAS STATION Q 2 DISTRIBUTOR D R SERVATION #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> 3 FARM 4 PROCESSOR OTHER OR TRUST LANDS / <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FI ST) ^ PHONE#WITHAREA COPE DAYS: NAME(LAST,FIRST) <br /> PHONE 2 WITH AREA CODENIGHTS: NAME(LAST,FIRS PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE v WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME /{ CARE OF ADDRESS INFORMATION <br /> �L l LG� l�M1,r.G 4 <br /> MAILING OR STREETADDRESS ✓ mxmlmk I� INDIVIDUAL LOCALAGENCY STATE-AGENCY <br /> O 0 CORPORATION 0 PARTNERSHIP L-1 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 3 /�/c she/ _ - 8 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS - . O ✓ Aoxbim: a = INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY <br /> (/-`" =CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-F4-1- _��Iy"�'-)`� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ OoxbindkM O I SELF-INSURED O 2 GUARANTEE 0 A INSURANCE O 4 SURELY BOND <br /> O 5 LETTER OF COEDIT �6 EXEMPTION Ij W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or IL's c ked. <br /> CHECK ONE BO%INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# # L.I r EM 29 <br /> LOCATbN�D� -OPTIONAL CENSUS TRACT# -�TIG4IAL SUPVI930R DISTRICT CODE -OPT L <br /> O11) v !C—D r— 3 - <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(5-91) <br /> F DO66A3 <br />